Failure to Administer Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident was not administered their prescribed morning medications as ordered on June 13, 2025. Record review and interviews confirmed that the resident did not receive multiple medications, including Furosemide, Folic Acid, Ferrous Sulfate, Docusate Sodium, Amlodipine Besylate, Amiodarone HCl, Losartan Potassium, Metformin HCl, Metoprolol Succinate, Gabapentin, and Acetaminophen. The Medication Administration Record (MAR) for that date did not show documentation of medication administration, and there was no record of vital signs being obtained. An SBAR note in the medical record also indicated that the resident was not given their morning medications. Interviews with staff revealed that nurses are expected to document medication administration immediately after giving medications and to note reasons for any missed doses. The Director of Nursing confirmed that the incident was reported and substantiated, and the facility's incident report noted that the nurse assigned to the resident had a disorganized medication cart and spent significant time searching for medications. The nurse involved did not provide a statement regarding the incident.